Provider Demographics
NPI:1699967612
Name:DECKER, MIRANDA (MD)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:535 GANDY ST
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-0516
Mailing Address - Country:US
Mailing Address - Phone:256-332-1120
Mailing Address - Fax:256-332-1198
Practice Address - Street 1:535 GANDY ST NE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1965
Practice Address - Country:US
Practice Address - Phone:256-332-1120
Practice Address - Fax:256-332-1198
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL28146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-06343OtherBCBS
AL009911825Medicaid